565800983-2-8-2022-29-AS-KLOZ-CBG2K5-20220208162721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800983
Report Date: 02/08/2022
Date Signed: 02/08/2022 04:29:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LINA'S GUEST HOME		FACILITY NUMBER:	565800983
ADMINISTRATOR:	CELINA B. ALBUNA		FACILITY TYPE:	740
ADDRESS:	2221 KEPLER DRIVE		TELEPHONE:	(805) 487-3816
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 3	DATE:	02/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:11 PM
MET WITH:	Lina Albuna		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. The LPA met with Administrator/Licensee Lina Albuna and explained the reason for the inspection. There are three residents in the home of which two are receiving home health services.

This annual had a specific emphasis on infection control practices and procedures. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The kitchen and food storage areas in the kitchen and garage were observed. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Cleaning supplies and items that could pose a danger were secured. Medications are centrally stored and locked in a cabinet in the kitchen.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good in condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced on 08/31/2021. The carbon monoxide detector and smoke detectors in the home and bedrooms were tested and were operational. The backyard has covered seating for resident use.

BEDROOMS: There are three resident bedrooms and one staff bedroom. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LINA'S GUEST HOME	FACILITY NUMBER: 565800983
	VISIT DATE: 02/08/2022

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RESTROOMS: The facility has two common restrooms for resident use, with one restroom that has access to a resident bedroom. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 2:28 PM, the hot water temperature measured at 116.8 degrees F. in the restroom that also connects to a resident bedroom.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. Infection control signs were posted at the entry, throughout the facility, and in the restrooms. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview and reported reviewed with the Administrator. A copy of the report was emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022

LIC809 (FAS) - (06/04)

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